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Igo Goldberg M.D, Hand Surgeon Tel-Aviv, Israel

Radiographic Examination of the Wrist. Igo Goldberg M.D, Hand Surgeon Tel-Aviv, Israel. IMAGING INVESTIGATIONS. Routine (screening) radiographic examination Specialized radiographic projections Scintigraphic examination Arthrography CT MRI Diagnostic arthroscopy (ARS).

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Igo Goldberg M.D, Hand Surgeon Tel-Aviv, Israel

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  1. Radiographic Examination of the Wrist Igo Goldberg M.D, Hand Surgeon Tel-Aviv, Israel

  2. IMAGING INVESTIGATIONS • Routine (screening) radiographic examination • Specialized radiographic projections • Scintigraphic examination • Arthrography • CT • MRI • Diagnostic arthroscopy (ARS)

  3. Which radiographic views should be obtained in the evaluation of every patient with wrist injury? “Routine Wrist Radiography” PA OBLIQUE LATSUPINATED OBLIQUE

  4. How should the standard (PA) radiogram for the examination of the wrist be obtained? • כתף באבדוקציה ל-90 מע', מרפק בכיפוף ל-90 מע', כף היד (ולא שורש היד) שטוחה על הקסטה (ללא כיפוף,יישור או הטיות לצדדים). • הקרן המרכזית של הרנטגן מאונכת לקסטה ומרוכזת על ראש עצם הקפיטטום • (קסטה גדולה מספיק בכדי להדגים את מלוא אורכן של עצמות המסרק). “90-90 position”

  5. קריטריונים לצילום נכון: 1 • (יש להדגים את כל אורך המטקרפוס השלישי). • המיקום של הסטילואיד האולנרי מראה האם הצילום נעשה בתנוחת PA או AP . • הופעת התעלה של ECU רדיאלית לסטילואיד אולנרי מראה שהמרפק היה בגובה הכתף בזמן הצילום, כפי שאכן צריך להיות. • ציר האורך של עצם המסרק צריך להיות בקו ישר להמשך ציר האורך של הרדיוס, מה שמצביע שלא היו הטיות לצדדים בזמן הצילום. • קווי הפרקים הקרפומטקרפלים 2-5 צריכים להיות מקבילים שאם לא כן שורש היד היה בכיפוף או ביישור. • Scaphoid fat pad 4 5 6 2 3

  6. Why is it important to obtain adequate PA view of the wrist? Ulnar variance measurements should not be made on a PA view of the wrist that does not meet the above criteria because there is a difference in the ulnar length on different position of the forearm and elbow: pronation gives the impression of positive ulnar variance and supination gives the impression of negative ulnar variance; adduction of the elbow towards the patient’s side usually makes the ulna more positive. PA with forearm pronation and firm grip PA AP Conventional PA

  7. NO !

  8. What are we looking for on PA views? L2 L3 L1 radial inclination Normal = 16-30 Mean=22 radial length Normal = 9 mm Gilula’s arcs carpal height = L1/L2 normal = 0.54 +/- 0.03 carpal translation = L3/L2 normal = 0.3 +/- 0.03 Modified carpal height ratio= L3/L2 normal = 1.57 (+/- 0.05

  9. 1.RADIAL LENGTH & INCLINATION radial inclination Normal =16-30 Mean=22 deg. radial length Normal = 9 mm

  10. 2.GILULA’S ARCS

  11. 3. CARPAL HEIGHT & CARPAL TRANSLATION RATIO L1 L1 carpal height ratio = L2/L1 normal = 0.54 +/- 0.03 L3 L2 ככל שהיחס קטן – התמט של שורש היד גדל carpal translation ratio = L3/L1 normal = 0.3 +/- 0.03 L1 L1’ L1’’

  12. CARPAL HEIGH RATIO - modified L3 L2 ככל שהיחס קטן – התמט של שורש היד גדל modified carpal height ratio = L2/L3 Normal = 1.57 (+/- 0.05)

  13. 4.ULNAR VARIANCE The relationship between the distal articular surfaces of the radius and ulna as seen on a standardized PA view of the wrist

  14. What are the three methods of measuring ulnar variance? Project-a-line technique Concentric circle method Method of perpendiculars

  15. 5. IMPACTION SYNDROMES U.S.P.I =C-B/A=0.21+/-0.07 Ulnar styloid impaction syndrome Ulnar impaction syndrome Ulnar impingement syndrome Ulnocarpal impaction syndrome 2ndary to ulnar styloid nonunion Hamatolunate impaction syndrome

  16. How should the standard lateral view of the wrist be obtained? • Elbow flexed to 90 deg. and adducted against the trunk • No flexion or extension of the wrist • The pronator quadratus fat pad is seen and is straight. • Scaphopisocapitate (SPC) relationship

  17. Adequacy of the projection: thescaphopisocapitate (SPC) relationship The volar-most edge of the pisiformis is within the boundaries of the scaphoid and volar-most edge of the capitate the ulna should be within 3 mm of the radial cortex

  18. SPC relationship in LAT projection True Lat

  19. What are we looking for on LAT views? • PALMAR TILT • CARPAL INSTABILITY ANGLES • INTRASCAPHOID ANGLES • RELATIONSHIP BETWEEN THE SCAPHOID & LUNATE IN FLEXION & EXTENSION OF THE WRIST

  20. 1.PALMAR TILT 90 deg. – the tilt is zero degrees. Palmar tilt is identified by (+) sign Dorsal tilt is identified by (-) sign Normal = +11 deg

  21. Intercarpal angles of carpal instability Radiolunate angle = 0 - 10 (either volar or dorsal lunate angulation) Capitolunate angle = 0 - 15 Radioscaphoid = 120 -150 Scapholunate angle = 30 - 60 2.CARPAL INSTABILITY ANGLES Collinear alignment of the radius, lunate and capitate: Lines are perpendicular to radiolunate and lunocapitate articulations

  22. Carpal instability angles: radiolunate angle R L 10 deg. either volar or dorsal lunate angulation > +10 deg. susp.DISI < -10 deg. Susp.VISI

  23. Carpal instability angles: capitolunate angle 0-15 deg. L C VISI DISI

  24. Carpal instability angles: radioscaphoid angle R 120 – 150 deg. S S’ C pattern V pattern (S-L dissociation)

  25. S Carpal instability angles: scapholunate angle L DISI Lunate dorsiflexed Scaphoid palmarflexed VISI Lunate volarflexed Scaphoid palmarflexed

  26. Example of combination of PA and LAT views:…… Disrupted Gilula’s arc at L-T joint volarflexed lunate and scaphoid Lunotriquetral lig. disruption (VISI)

  27. 3.INTRASCAPHOID ANGLES Lateral intrascaphoid angle Posteroanteriorintrascaphoid angle Normalangles < 35 deg. > 45 deg. Increased risk for OA changes

  28. “Routine wrist radiography” כף היד צ"ל שטוחה על הקסטה OBLIQUE SUPINE PA LAT OBLIQUE

  29. “Routine wrist radiography” PA LAT Oblique Supinated Oblique “Wrist motion view series” Clenched-fist AP (Clenched-fist PA with UD) PA view in: neutral radial deviation ulnar deviation LAT view in: neutral dorsiflexion volarflexion Of which radiographic views consists the “wrist instability series” described by Gilula?

  30. CLENCHED- FIST AP The intercarpal spaces of a normal wrist will not appear different than on a nonstressed AP projection

  31. CLENCHED - FIST PA(a matter of personal preference) The intercarpal spaces of a normal wrist will not appear different than on a nonstressed AP projection

  32. PA NEUTRAL

  33. PA RADIAL- DEVIATION PA ULNAR-DEVIATION Proximal raw dorsiflexes Proximal raw palmarflexes SCAPHOID foreshortened elongated LUNATE quadrangular triangular TRIQUETRUM Proximal (“high position”) Distal (“low position”)

  34. VISI DISI

  35. LAT NEUTRAL

  36. LAT in FLEXION LAT in EXTENSION Scaphoid: 35 extension Scaphoid: 75 flexion Lunate: 50 flexion Lunate: further 30

  37. מרכזי צמיחה 2 2 2 2 1 6 1 7 12 1 3 5 4 1 6

  38. הערכה רנטגנית של שורש היד וכף היד A1= “radial angulation” 120-125 deg. A2= ulnar deviation of the fingers Pathological >25 deg. L2/L1= “carpal heigh” 0.54+/-0.03 L3/L1= “ulnar translocation” 0.30+/-0.03

  39. הערכה רנטגנית של שורש היד וכף היד:Rheumatoid arthritis

  40. הערכה רנטגנית של שורש היד וכף היד:Rheumatoid arthritis

  41. CESAREA MARITTIMA Thank you !

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